Date Date Format: MM slash DD slash YYYY DoctorOwner’s Name* First Last Pet’s Name*WeightPerson to contact if more information is needed?*Why are we seeing your pet? (Please be specific. If a lump or area of the body is to be examined, be sure to show the receptionist or technician exactly where it is.)*When did you first notice the problem?*Have there been any changes since you first noticed the problem? (Getting Better? Worse?)Has this been a recurrent problem? Last episode?Is your pet eating?*Yes – NormallyYes – A little less than normalYes – A LOT less than normalNo – Not eating at allIs your pet drinking?*Yes – NormallyYes – A little less than normalYes – A LOT less than normalNo – Not eating at allIs your pet vomitting?*YesNoIf yes, how often, large or small amounts, is food present, is it fluid only?*Does your pet have diarrhea?*YesNoIf yes, how often, large or small amounts, is there urgency, any accidents in the house?*Is your pet coughing?*YesNoWhat does it sound like?*Is your pet sneezing?*YesNoHow often, is it in a series, any noted triggers?*List any medication your pet is taking, including over the counter medication such as aspirin The office visit charge at this hospital is $45.00. Animals dropped off for examination will be looked at between 9:00 AM and 5:30 PM, unless you have requested a specific doctor. There is always the likelihood that further testing will be required to fully answer the questions you have about your pet. In most cases, a discharge time will be established for your pet which will enable you to talk to the veterinarian and ask any questions you may have. Bethany Animal Hospital does not offer 24 hour care. Please select:Contact me before running any tests or beginning therapyThis patient is from a rescue. Please contact them first before running tests or beginning therapy.I authorize testing that the doctor may deem necessary up to:* $163.40 for the Superchem/CBC Panel $202.30 - $209.34 for the Comprehensive Panel Urinalysis $62.12 Radiographs (X-rays) up to $130.50 I authorize tranquilization of my pet if the doctor deems it necessary to fully evaluate my pet. Between $75.00 and $175.00. Signature of Owner/Agent/Foster*
